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Scientific Basis of Clinical Practice > GI Pathology > Flashcards

GI Pathology Flashcards

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1
Q

describe the structure of the oesophagus

A

lined by squamous mucosa
separated from the submucosa by the muscularis mucosa
deep to this; muscularis propria, with the inner circular and outer longitudinal bundles of smooth muscle

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2
Q

describe the conditions involving oesophageal stenosis

A

congenital stenosis/atresia; generally paediatric, associated with fistula

thoracic oesophageal malignancy; rarely fistulae into the trachea or one of the main bronchi, frequently leading to mediastinitis and sepsis

achalasia; rare, dysmotility of the distal oesophagus causes dilatation of the proximal oesophagus, can precipitate infection, inflammation and epidermoid metaplasia, can predispose to squamous carcinoma of the oesophagus

liver cirrhosis and elevation of venous pressure in portal venous circulation; engorgement and dilatation of the vascular channel at sites of portal systemic anastomosis, can precipitate oesophageal varices formation
bleeding and haematemesis

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3
Q

describe oesophagitis

A

most common cause is reflux oesophagitis
cause; regurgitation of the gastric contents into the lower oesophagus
results from incompetence of the lower oesophageal sphincter
symptoms; heartburn, water brash, odynophagia

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4
Q

what are the complications of oesophagitis?

A

ulceration and necrosis of the squamous epithelial lining; acute inflammation
stricture and stenosis; repeated long-term acute inflammation
fibrosis and structuring; chronic inflammation
Barrett’s metaplasia

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5
Q

describe Barrett’s oesophagus

A

the stratified squamous epithelial lining is replaced by a columnar epithelial lining/mucosa in the distal 1/3rd of the oesophagus
endoscopy; appears red and velvety vs white native squamous mucosa
can only be detected by endoscopy
histology; squamous mucosa replaced by mate plastic intestinalised columnar mucosa

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6
Q

describe candidal infection of the oesophagus

A

often seen in immunosuppressed patients; diabetes, HIV, AIDS
endoscopy; raised white plaques
microscopy; fungal hyphae, can be accentuated using periodic acid shift

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7
Q

describe herpes oesophagitis

A

linear, punched out ulcers within the oesophagus
microscopy; viral infection, multinucleate squamous epithelial cells, containing ground glass viral inclusions
particularly seen in leukaemia and lymphoma
associated with odynophagia

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8
Q

describe eosinophilic oesophagitis

A

common in young adult males
often present with dysphagia
concentric rings; trachealisation of the oesophagus/feline oesophagus
histology; numerous eosinophils within the squamous epithelium
eosinophilia in the peripheral blood
increased serum try-taste
eosinophilic infiltrates in other parts of the GI tract

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9
Q

describe the different types of cancer of the oesophagus

A

squamous carcinoma; commonest in middle 1/3, commonest in Asia and Iran
adenocarcinoma; comment in distal 1/3, particularly prevalent in obese middle-aged caucasians
more common in males

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10
Q

what are the risk factors for squamous carcinoma of the oesophagus?

A 
alcohol
tobacco
dietary nitrosamines
types of fungi
achalasia
genetic predisposition; tylosis
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11
Q

what are the risk factors for adenocarcinoma of the oesophagus?

A

GORD
obesity/body habitus
barrett’s oesophagus
alcohol/tobacco

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12
Q

what are the patterns of oesophageal cancer?

A

necrotising malignant ulcer eroding into the wall or adjacent structures
exophytic, polypoid luminal mass
3 diffuse infiltrative neoplasms resulting in stricture

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13
Q

describe Barrett’s metaplasia/oesophagus

A

a pre-malignant condition
risk factor for oesophageal adenocarcinoma
patients are followed by endoscopic surveillance to detect pre-malignant dysplastic change

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14
Q

what is the treatment of dysplastic Barrett’s tissue?

A

can be destroyed by an endoscopic procedure
insertion of a radio frequency ablation device and ablating the abnormal mucosa
only destroys to a depth of a few hundred micrometers
insufficient to treat early cancers

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15
Q

describe endoscopic mucosal resection

A

can treat early Barrett’s related oesophageal adenocarcinoma with a low risk of nodal metastasis
but 90% of oesophageal adenocarcinomas present with advanced disease

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16
Q

describe the staging of oesophageal carcinoma

A

T1; confined to the innermost layers of the wall
pT1a; intramucosal disease, have not breached the muscularis mucosa
T3; break through the muscularis propria into the surrounding oesophageal adventitial fat
N1 etc; nodal involvement

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17
Q

describe the presentation of oesophageal carcinoma

A

most common; pT3N1
dysphagia
weight loss
may have occult metastatic disease; PET scan

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18
Q

what is the treatment of oesophageal carcinoma?

A

dependent on stage
early lesions; endoscopic mucosal resection
more advanced; oesphagectomy
pT3N1; neoadjuvant chemotherapy, then surgery
middle 1/3 tumours and showing squamous morphology; radical chemoradiation
surgically incurable; palliative chemotherapy
HER2 positive; trastuzumab
very unwell; palliative stenting

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19
Q

describe acute erosive gastritis

A

small punctuate areas of erosion and inflammation in the gastric mucosa
seen in endoscopy

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20
Q

what are the causes of acute erosive gastritis?

A 
NSAIDs
iron tables
alcohol
corrosive substance ingestion
systemic chemotherapy
uraemia; CKD
shock; widespread burns
sepsis
recent major surgery
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21
Q

what are the types and causes of chronic gastritis?

A

type A; autoimmune gastritis, associated with pernicious anaemia and lymphocytic infiltrate within the gastric mucosa
type B; chronic active gastritis due to h. pylori infection
type C; distinctive pattern of mucosal injury and regenerative change associated with the exposure of the gastric mucosa to certain types of chemical, NSAIDs, alcohol

most common cause; reflux of bile or duodenal contents
seen sporadically or in previous gastric surgery

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22
Q

describe h. pylori infection

A

gram negative rod shaped organism
results in chronic active inflammation
secretes urease, breaks down urea to ammonia, resulting in local pH buffering, allowing bacteria to survive
certain strains also produce cytotoxins and incite and inflammatory reaction in the mucosa
can be tested with the ammonia breath test at endoscopy

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23
Q

what are the complications of helicobacter infection?

A 
chronic active gastritis
peptic ulcers; gastric and duodenal
corpus gland atrophy
intestinal metaplasia
gastric carcinoma
gastric lymphoma
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24
Q

what are the features and complications of peptic ulcers?

A

haematemesis; coffee grounds
perforation
scarring and stenosis of pylorus; pyloric outlet obstruction

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25
what are the types of gastric carcinoma?
intestinal type | diffuse/poorly cohesive type
26
describe the intestinal type gastric carcinoma
neoplastic cells form glandular structures that are readily appreciable particularly prone to lymphovascular invasion and haematogenous spread more liver metastases seen
27
describe the diffuse/poorly cohesive type gastric carcinoma
single cell pattern, single dispersed cancer cells infiltrate between and around pre-existing gastric mucosal gland structures tumour cells adopts a signet ring cell morphology may diffusely infiltrate and involve the stomach wall the stomach loses its normal functional ability and becomes rigid more peritoneal cavity spread; krukenberg tumours
28
what are the clinical features of gastric carcinoma?
``` asymptomatic weight loss epigastric mass haematemesis vomiting virchow's node; metastasis to the supraclavicular lymph node ```
29
describe krukenberg tumour
spread through the peritoneum to involve the ovaries and give rise to bilateral ovarian metastases
30
describe the diagnosis and treatment of gastric carcinoma
laparscopy with peritoneal washings; detection of peritoneal metastases malignant cells in the fluid; contraindication to surgery removal at primary site is futile if it has spread to the peritoneal cavity
31
describe gastric lymphoma
longstanding h. pylori chronic gastritis can result in lymphoid follicle formation and accumulation of mucosa associated lymphoid tissue; MALT antigen-dependent polyclonal reactive lymphoid proliferation can progress to low-grade lymphoma
32
what are the histological features of gastric lymphoma?
confluent patterns of growth of the follicles destruction of the pre-existing native gastric mucosal glands by the formation of lymphoepithelial lesions associated with monoclonality
33
what is the treatment of gastric lymphoma?
h. pylori eradication sometimes causes regression of the lymphoid infiltrate antibiotics cytotoxic chemotherapies surgery conventional lymphoma treatment; spread from another histological type of lymphoma conventional anti-lymphoma treatment; primary gastric marginal zone lymphoma, primary gastric lymphoma, secondary lymphoma
34
describe GI stromal tumours
mesenchymal spindle cell tumours most commonly found in the stomach and the small bowel dumbbell configuration sometimes ulceration in relation to the overlying gastric mucosa seen clearly on CT difficult to obtain diagnostic preoperative biopsies; ulcer slough
35
what are the consequences of GI stromal tumours?
mostly small, benign and incidental findings larger; can be associated with haemorrhage and haematemesis, behave more aggressively small bowel; more aggressive, behave more malignantly malignancy; can spread through the peritoneal cavity and develop liver metastases uncommon to metastasise to local regional lymph nodes
36
describe CD 117 or c-kit expression of GI stromal tumours
tyrosine kinase gene mutation susceptible to imatinib (selective TKI) also show exon 11 of KIT gene mutations
37
what tumours can affect the small bowel?
``` adenocarcinoma carcinoid tumours GI stromal tumours malignant lymphoma metastases ```
38
describe small bowel adenocarcinoma
less common than primary colonic adenocarcinoma; may be metastatic spread mostly sporadic commonly duodenal; napkin ring stricture associated with crohn's and coeliac disease often presents late with poor prognosis
39
describe duodenal tumours
may be associated with FAP | often polypoid
40
what are the common sites of primary colonic adenocarcinoma metastases?
small bowel lung ovary breast
41
describe the grading of carcinoid tumours
1; low-grade malignant tumours, usually primary appendices carcinoids 3; morphological overlap with small cell carcinoma or large cell neuroendocrine
42
describe carcinoid syndrome
the release of serotonin/5-hydroxytryptamine into the systemic circulation via the hepatic vein from liver metastases facial flushing sweating wheezing diarrhoea long term; endocardial fibrosis in tricuspid and pulmonary valves, associated with RSHF
43
how is carcinoid syndrome diagnosed?
urinary 5-hydroxyindoleacetic acid (5-HIAA) levels | octreotide or somatostatin scan
44
what syndromes are carcinoid tumours associated with?
Zollinger-Ellison syndrome; hypergastrinaemia, carcinoid tumour in the 1st part of the duodenum hypergastrinaemia; peptic ulceration MEN-1
45
describe the histological features of carcinoid syndrome
cells with granular eosinophilic cytoplasm monotonous, low grade features of malignancy insular or trabecular pattern in a fibrovascular stroma, can sometimes contain amyloid
46
describe GI stromal tumours of the small bowel
less common more aggressive c-KIT mutations; imatinib exon 9 of KIT gene mutations; implications for blockade of TK with imatinib
47
describe malignant lymphoma of the small bowel
common site; 25-30% of GI lymphomas | may be primary or secondary
48
what are the types of malignant lymphoma of the small bowel?
MALToma Burkitt's lymphoma follicular lymphoma mantle cell lymphoma enteropathy associated T cell lymphoma (EATL) post transplant lymphoproliferative disorder
49
describe MALToma of the small bowel
associated with h. pylori infection | represent a form of low-grade B-cell non-hodgkin's lymphoma
50
describe Burkitt's lymphoma
``` relatively uncommon high-grade B-cell non-Hodgkin's lymphoma associated with EBV associated with immunosuppression common in children and young adults frequently seen in the terminal ileum very chemo-responsive ```
51
describe folicular lymphoma
low-grade B-cell non-hodgkin's lymphoma frequently in mesenteric lymph nodes can occur as a primary neoplasm, particularly within the duodenum
52
describe mantle cell lymphoma
very strongly associated with the GI tract usually involves the colon can form multiple polypoid masses, resulting in multiple lymphomatous polyposis intermediate grade B-cell lymphoma
53
describe enteropathy associated T-cell lymphoma (EATL)
aggressive, high-grade, T-cell, non-hodgkin's lymphoma very strongly associated with the jejunum and ileum can be associated with coeliac disease refractory coeliac disease; prodromal syndrome or a pre-malignant condition
54
describe post-transplant lymphoproliferative disorders
associated with immunosuppression; treatment of IBD EBV-driven disorder most common in renal and other transplants
55
describe metastases of the small bowel
relatively common more common that metastases to the large bowel primary sites; lung, ovary, stomach, breast carcinoma, metastatic melanoma lobular carcinoma of the breast; most common breast carcinoma that metastasises to the small bowel, also involves the mesentery and retroperitoneum
56
describe polyps
raised lesion within the lumen of the GI tract arises within the wall often pre-malignant most common types; hyper plastic and adenomatous hamartomatous polyps; can occur as an inherited polyposis syndrome, Peutz Jeghers syndrome or juvenile polyposis
57
describe hyperplastic polyps
``` very common very little malignant potential appear as small polypoid lesions often on the folds of mucosa show serrations; localised hyperplasia of the colonic mucosa ```
58
describe adenomatous polyps
very common dysplastic; indicated an increased risk of malignancy can range from a few mm to several cm predominately tubular or villous architecture
59
what features of a polyp indicate malignancy?
size degree of dysplasia type; tubular polyps have a lower risk of dysplasia than those with a villous projection
60
describe serrated polyps
hydra between the hyperplastic and adenomatous polyp do not show the same conventional type of dysplastic change that is seen in adenomatous polyps have pre-malignant potential
61
describe FAP
AD inheritance mutation of the APC gene on the long arm of chr 5 growth of many hundreds of adenomatous polyps throughout the large bowel increased chase of developing colorectal carcinoma
62
what is the management of carcinoma within the polyp?
invasive adenocarcinoma in a pedunculated polyp; endoscopic snare polypectomy sessile adenomatous polyps; difficult to remove because of mechanical reasons and because they may be associated within invasion of the wall and earlier spread
63
what are the identifiable causes of colorectal adenocarcinomas?
10% in total; 5%; HNPCC/Lynch syndrome, results in genetic micro-satellite instability 2%; history of IBD, particularly UC (those with severe UC ~10yrs will have sclerosing cholangitis)
64
describe the adenoma carcinoma sequence
a morphologically defined progressive sequence of changes associated with tumour development and progression can be associated with increasing numbers of molecular abnormalities, mutations within tumour suppressor genes and and oncogenes
65
describe the vogelstein model of the adenoma carcinoma sequence
``` normal epithelium dysplastic ACF early adenoma late adenoma cancer metastatic cancer ```
66
describe the presentation of right-sided colon tumours
iron deficiency anaemia; ulcerating tumour causing blood loss over a prolonged period of time
67
describe the presentation of left-sided colon tumours
change in bowel habit crampy abdominal pain intestinal obstruction; solid stool, thicker wall, smaller lumen
68
what investigations are required to stage a colorectal cancer?
MRI; rectal cancer staging CT chest, abdomen and pelvis; nodal status, examine the liver serum CEA; useful in following the progress of a tumour in patients receiving oncological treatment
69
what is the treatment of colorectal cancer?
surgery; removal of the segment of bowel affected, associated with the relevant anatomical lymph node drainage groups adjuvant chemotherapy; to prolong disease-free survival in node positive patients radiotherapy; primarily for rectal cancer, used prior to surgery or in combination with chemotherapy
70
describe rectal tumour surgery
mesorectal excision margin; extraperitoneal middle and distal 1/3 of the rectum all of the tissue is removed en bloc prevention/reduction of the indigence of local/pelvic recurrence of rectal adenocarcinoma
71
describe the non-surgical rectal tumour treatment
more bulky and advanced; incomplete tumour resection and recurrence pre-operative radiotherapy short course radiotherapy combination chemotherapy and radiotherapy long course chemoradiotherapy

Scientific Basis of Clinical Practice (10 decks)

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